England's Grand Mental Health Care Experiment

Did "the World's Most Ambitious Effort" to Expand Treatment Fall Flat?

Almost 10 years ago, England embarked on what would become one of the nation’s largest expansions of mental health care coverage. The architects of the Improving Access to Psychological Therapies (IAPT) initiative had an ambitious goal: to expand mental health care to as many people who needed it as possible, through evidence-based methods like cognitive behavioral therapy (CBT). In 2005, when the plan was first pitched to Parliament, one in four adults suffered from at least one diagnosable mental health problem, according to statistics from the National Institute for Clinical Excellence (NICE), the government body that sets standards on clinical treatments. And according to research published a year earlier in The British Journal of Psychiatry, depression alone was costing the English economy nearly nine billion pounds annually in lost productivity and unemployment benefits. If at least some suffering people recovered and went back to work, proponents argued, unemployment payouts would drop and the program would pay for itself. But could psychotherapy—at its core, most clinicians would argue, a process based on the development of relationships—really be systematized on a nationwide scale?

What began as a highly anticipated experiment quickly fell flat. To start, retention rates have been low: reports released in 2015 by the National Health Service (NHS) revealed that only 37 percent of those who’d entered the IAPT program—after going through the required referrals from their general practitioners—completed the allotted 12-session treatment, while those providing treatment have been criticized as unprepared. Exclusively green-lighting methods like CBT has also caused an uproar among many in the clinical community. IAPT has also taken heat for its multitiered treatment system, including many practitioners with little training. Clients can eventually see therapists in person, but the first gatekeepers in IAPT are call center workers with little professional experience and only one year of CBT training.

So how did a program like IAPT even get off the ground? The principal architect is Richard Layard, an economist, professor, and director of England’s Centre for Economic Performance. When he developed the IAPT initiative, Layard was nearly five years into his tenure as an honorary peer in the House of Lords. During the 1990s, he’d become captivated by happiness economics, the study of forces that lead people to a happy or unhappy life. After a chance encounter at a party in 2003 with clinical psychologist David Clark, a leading CBT researcher, Layard was won over by the potential that Clark touted CBT had to stem the nation’s growing depression and anxiety rates. Knowing the issue of mental health care would be a hot topic in the 2005 general elections, the two co-wrote a manifesto on behalf of the Labour Party, vowing “to invest in and improve our services for people with mental health problems at primary and secondary levels, including behavioral as well as drug therapies.”

After the Labour Party won by a narrow margin, the two set about reinventing British mental health care, the goal being not “wealth creation,” but “wellbeing creation,” Clark said in a 2016 study published by the London School of Economics. In the past, he stated, “the state has successively taken on poverty, unemployment, education, and physical health. But equally important now are domestic violence, alcoholism, depression and anxiety conditions, alienated youth. . . . These should become centre stage.”

Under Layard and Clark’s plan, England’s mental health care budget more than doubled—from nearly 80 million to 170 million pounds—so that a minimum of 15 percent of adults with depression and anxiety would receive treatment, up from just 3 percent. It’s a level of spending on mental health care that’s unmatched in the developed world. In July 2017, The New York Times dubbed IAPT “the world’s most ambitious effort to treat depression, anxiety, and other common illnesses.” And it continues to grow. According to NHS estimates, more than 900,000 people access IAPT services annually, a figure the NHS hopes to boost to 1.5 million by 2021. The program, according to Layard, currently employs more than 6,000 therapists.

Scott Miller, a psychologist who codirects the Center for Clinical Excellence, an international consortium of clinicians and researchers dedicated to promoting best practices in mental health, says Americans can learn—and should admire—much in IAPT. “First of all, look at what England was willing to invest in mental health care—billions upon billions of pounds,” he says. “Sure, there have been problems in terms of implementation. But access to psychological care has increased every year since the program’s inception.” In England, he adds, “there’s no shortage of people interested in therapy.”

Still, for many, IAPT’s benefits are overshadowed by its poor execution. The most frequent point of contention among therapists seems to be the exclusion of any methods that aren’t considered evidence based. “Before IAPT, I used to have freedom to use different modalities with clients,” says London-based psychotherapist and former NHS employee Martin Pollecoff. “I don’t anymore.” Many therapists, Pollecoff recalls, felt optimistic when IAPT was first introduced. “This was going to be a revolution in which every person who needed therapy would get it,” he says. “But what we wound up with instead was a manualized process in which any therapy that wasn’t CBT was derided.” By nature, Pollecoff says, therapy isn’t a science. And Layard and Clark, he continues, saw therapy not as a relationship between two people, but as a matter of economics, IAPT’s questionnaires and manuals “reducing therapy to a lab test.”

Gillian Proctor, a counseling professor at the University of Leeds, spent nearly 10 years training therapists to work within IAPT. Like Pollecoff, she argues that an overreliance on statistics and clinical trial recovery rates holds clinicians to unrealistic standards. “A lot of people are saying their clinical expertise and responsibilities as they’ve known them are no longer applicable,” she says, adding that IAPT employees are often managed by government officials who have little to no clinical background, and are paid only if they meet the strict recovery-rate standards put in place by NICE. “IAPT operates using a very top-down managerial approach,” she adds, “where people are told what to do, and if they’re not providing good enough outcomes, then there’s a lot of pressure put on them as to why they’re not delivering.” Between off-site management, little room for collaboration between clinicians, and low-intensity therapy that “barely qualifies as CBT,” Proctor says that among IAPT therapists, morale is low and burnout high.

In response to criticism, David Clark reported in the April 2015 issue of The British Journal of Psychiatry that IAPT would “support the training and employment of therapists who can deliver [four other] therapies that NICE recommends”—counseling, couples therapy, interpersonal psychotherapy, and brief psychodynamic therapy. But he also offered a rebuttal to the pushback that therapy should prioritize the therapist–client relationship, and to the chagrin of many clinicians, restated that IAPT would stand exclusively behind evidence-based methods.

In a 2016 statement, the NHS acknowledged its low recovery rate and promised to investigate specific problems in low retention, particularly among black and ethnic minority communities. “There is more work to do in some areas,” the statement read. “Peer support from commissioning groups who are taking an exemplary approach is helping improve other services.” However, problems persist. In 2017, the NHS again announced its intention to build in more robust follow-up measures for IAPT, although it’s not yet clear what this might entail.

In the meantime, there’s been no slowing down in government investment in IAPT. With a current annual budget of more than 350 million pounds, spending on IAPT programs is expected to double over the next few years. For now, the clinical community is keeping watch, taking stock of what IAPT has accomplished, and making note of what needs to be improved. But therapists like Pollecoff say they’ll be fighting an uphill battle. “Psychotherapy has always been about the human relationship,” he explains. “But IAPT has created industrialized therapy, and like any industrialized process, the sole objective is more productivity.”